Impact of Plan-Do-Study-Act Cycles on the Reduction of Errors Related to Vaccine Administration
Bibliographic Data
| ID | 21432995 |
|---|---|
| Authors | Mônica Batista Mendes Nunes (0000-0002-3271-8936, Universidade de São Paulo), Thalyta Cardoso Alux Teixeira (0000-0003-0513-7009, Universidade de São Paulo), Carmen Silvia Gabriel (0000-0003-2666-2849, Universidade de São Paulo), Fernanda Raphael Escobar Gimenes (0000-0002-5174-112X, Universidade de São Paulo, corresponding author) |
| Year | 2021 |
| Volume | 30 |
| Publication date | 2021-01-01 |
| Open Access | Yes |
| Type | ARTICLE |
| Venue | Texto & Contexto - Enfermagem (JOURNAL) |
| Journal identifiers | ISSN: 0104-0707 • E-ISSN: 1980-265X |
| Publisher | FapUNIFESP (SciELO) (PUBLISHER) |
| DOI | 10.1590/1980-265x-tce-2020-0225 |
| OpenAlex | W3182306865 |
| SciELO | S0104-07072021000100342 |
| Language | EN |
| References cited | 10 |
Objective: to evaluate the impact of a quality improvement program in the reduction of errors related to vaccine administration. Method: an intervention study aimed at comparing outcome measures before (Phase I) and after (Phase II) the implementation of a quality improvement program. It was carried out in a Basic Health Unit in the inland of São Paulo from March 2019 to November 2019. In the first phase, there was direct observation by Nursing professionals during the preparation and administration of the doses. In the second phase, an error was selected and subjected to four Plan-Do-Study-Act cycles to test the changes. The following quality tools were also used: root cause analysis, Ishikawa diagram and Pareto diagram. Results: a total of 164 doses of vaccines prepared and administered to 51 users were observed; 527 errors were identified and categorized into 13 types. In 27.7% of the observations made in Phase I, the users/guardians were not informed about potential adverse reactions. The goal of 100% of guidelines was established over an eight-month period, which was achieved in the second Plan-Do-Study-Act cycle and maintained in the third and fourth cycles, with confirmed improvement in the process. Conclusion: the quality improvement approach, based on Plan-Do-Study-Act cycles, contributed to the reduction of errors in the administration of vaccines and the change was sustainable, as it maintained over time
Administration (probate law) · Geography · Operations management · Pareto chart · Pareto principle · Phase (matter) · Plan (archaeology) · Political science · Quality (philosophy) · Quality management · Reliability engineering · Root cause analysis · Engineering · Intramuscular injections and effects · Medicine · Patient Safety and Medication Errors · Vaccine Coverage and Hesitancy
| Highly cited | No |
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